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OBJECTIVE We examined prevalences of previously diagnosed diabetes and undiagnosed diabetes and high risk for diabetes using recently suggested A1C criteria in the U.S. during 2003-2006. We compared these prevalences to those in earlier surveys and those using glucose criteria. RESEARCH DESIGN AND METHODS In 2003-2006, the National Health and Nutrition Examination Survey included a probability sample of 14,611 individuals aged > or =12 years. Participants were classified on glycemic status by interview for diagnosed diabetes and by A1C, fasting, and 2-h glucose challenge values measured in subsamples. RESULTS Using A1C criteria, the crude prevalence of total diabetes in adults aged > or =20 years was 9.6% (20.4 million), of which 19.0% was undiagnosed (7.8% diagnosed, 1.8% undiagnosed using A1C > or =6.5%). Another 3.5% of adults (7.4 million) were at high risk for diabetes (A1C 6.0 to <6.5%). Prevalences were disproportionately high in the elderly. Age-/sex-standardized prevalence was more than two times higher in non-Hispanic blacks and Mexican Americans versus non-Hispanic whites for diagnosed, undiagnosed, and total diabetes (P < 0.003); standardized prevalence at high risk for diabetes was more than two times higher in non-Hispanic blacks versus non-Hispanic whites and Mexican Americans (P < 0.00001). Since 1988-1994, diagnosed diabetes generally increased, while the percent of diabetes that was undiagnosed and the percent at high risk of diabetes generally decreased. Using A1C criteria, prevalences of undiagnosed diabetes and high risk of diabetes were one-third that and one-tenth that, respectively, using glucose criteria. CONCLUSIONS Although A1C detects much lower prevalences than glucose criteria, hyperglycemic conditions remain high in the U.S., and elderly and minority groups are disproportionately affected.

OBJECTIVE:--We examined the prevalences of diagnosed diabetes, and undiagnosed diabetes and pre-diabetes using fasting and 2-h oral glucose tolerance test values, in the U.S. during 2005-2006. We then compared the prevalences of these conditions with those in 1988-1994. RESEARCH DESIGN AND METHODS--In 2005-2006, the National Health and Nutrition Examination Survey included a probability sample of 7,267 people aged greater-than-or-equal12 years. Participants were classified according to glycemic status by interview for diagnosed diabetes and by fasting and 2-h glucoses measured in subsamples. RESULTS:--In 2005-2006, the crude prevalence of total diabetes in people aged greater-than-or-equal20 years was 12.9%, of which ~40% was undiagnosed. In people aged greater-than-or-equal20 years, the crude prevalence of impaired fasting glucose was 25.7% and of impaired glucose tolerance was 13.8%, with almost 30% having either. Over 40% of individuals had diabetes or pre-diabetes. Almost one-third of the elderly had diabetes, and three-quarters had diabetes or pre-diabetes. Compared with non-Hispanic whites, age- and sex-standardized prevalence of diagnosed diabetes was approximately twice as high in non-Hispanic blacks (P < 0.0001) and Mexican Americans (P = 0.0001), whereas undiagnosed diabetes was not higher. Crude prevalence of diagnosed diabetes in people aged greater-than-or-equal20 years rose from 5.1% in 1988-1994 to 7.7% in 2005-2006 (P = 0.0001); this was significant after accounting for differences in age and sex, particularly in non-Hispanic blacks. Prevalences of undiagnosed diabetes and pre-diabetes were generally stable, although the proportion of total diabetes that was undiagnosed decreased in Mexican Americans. CONCLUSIONS:--Over 40% of people aged greater-than-or-equal20 years have hyperglycemic conditions, and prevalence is higher in minorities. Diagnosed diabetes has increased over time, but other conditions have been relatively stable.

The health of younger adults in the U.S. has important public health and economic-related implications. However, previous literature is insufficient to fully understand how the health of this group has changed over time. This study examined generational differences in cardiovascular risk factors of younger adults over the past 40 years. Data were from 6 nationally representative cross-sectional National Health and Nutrition Examination Surveys (1971-2012; N = 44,670). Participants were adults age 20-49 years who self-reported sociodemographic characteristics and health conditions, and had examination/laboratory measures for hypertension, hyperlipidemia, diabetes, obesity, and chronic kidney disease. Prevalences of sociodemographic characteristics and health status were determined by study period. Logistic regression was used to determine the odds [odds ratio (OR), 95% confidence interval] of health conditions by study period: models adjusted only for age, sex, and race, and fully adjusted models additionally adjusted for socioeconomic characteristics, smoking, BMI, diabetes, and/or hypertension (depending on the outcome) were assessed. Participants in 2009-2012 were significantly more likely to be obese and have diabetes compared to those in 1971-1975 (OR = 4.98, 3.57-6.97; OR = 3.49, 1.59-7.65, respectively, fully adjusted). Participants in 2009-2012 vs. 1988-1994 were significantly more likely to have had hypertension but uncontrolled hypertension was significantly less likely (OR = 0.67, 0.52-0.86, fully adjusted). There was no difference over time for high cholesterol, but uncontrolled high cholesterol was significantly less likely in 2009-2012 vs. 1988-1994 (OR = 0.80, 0.68-0.94, fully adjusted). The use of hypertensive and cholesterol medications increased while chronic kidney and cardiovascular diseases were relatively stable. Cardiovascular risk factors of younger U.S. adults have worsened over the past 40 years, but treatment for hypertension and high cholesterol has improved. The sub-optimal and worsening health in younger adults may have a substantial impact on health care utilization and costs, and should be considered when developing health care practices.

OBJECTIVE: To compare the prevalence of prediabetes using A1C, fasting plasma glucose (FPG), and oral glucose tolerance test (OGTT) criteria, and to examine the degree of agreement between the measures. RESEARCH DESIGN AND METHODS: We used the 2005-2008 National Health and Nutrition Examination Surveys to classify 3,627 adults aged ≥18 years without diabetes according to their prediabetes status using A1C, FPG, and OGTT. We compared the prevalence of prediabetes according to different measures and used conditional probabilities to examine agreement between measures. RESULTS: In 2005-2008, the crude prevalence of prediabetes in adults aged ≥18 years was 14.2% for A1C 5.7-6.4% (A1C5.7), 26.2% for FPG 100-125 mg/dL (IFG100), 7.0% for FPG 110-125 mg/dL (IFG110), and 13.7% for OGTT 140-199 mg/dL (IGT). Prediabetes prevalence varied by age, sex, and race/ethnicity, and there was considerable discordance between measures of prediabetes. Among those with IGT, 58.2, 23.4, and 32.3% had IFG100, IFG110, and A1C5.7, respectively, and 67.1% had the combination of either A1C5.7 or IFG100. CONCLUSIONS: The prevalence of prediabetes varied by the indicator used to measure risk; there was considerable discordance between indicators and the characteristics of individuals with prediabetes. Programs to prevent diabetes may need to consider issues of equity, resources, need, and efficiency in targeting their efforts.

Trends in the Prevalence and Ratio of Diagnosed to Undiagnosed Diabetes According to Obesity Levels in the U.S. Edward W. Gregg , PHD 1 , Betsy L. Cadwell , MSPH 1 , Yiling J. Cheng , MD, PHD 2 , Catherine C. Cowie , PHD 3 , Desmond E. Williams , MD, PHD 1 , Linda Geiss , MA 1 , Michael M. Engelgau , MD 1 and Frank Vinicor , MD, MPH 1 1 Division of Diabetes Translation, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia 2 Division of Information Technology, Northrop Grumman, Atlanta, Georgia 3 National Institute of Diabetes, Digestive, and Kidney Diseases, National Institutes of Health, Bethesda, Maryland Address correspondence and reprint requests to Edward W. Gregg, PhD, Division of Diabetes Translation, Centers for Disease Control and Prevention, 4770 Buford Hwy., N.E., Mailstop K-10, Atlanta, GA 30341. E-mail: edg7{at}cdc.gov Abstract OBJECTIVE —To examine trends in the prevalence of diagnosed and undiagnosed diabetes and the proportion of total cases previously diagnosed, according to obesity status in the U.S. over the past 40 years. RESEARCH DESIGN AND METHODS —We assembled data from five consecutive cross-sectional national surveys: National Health Examination Survey I (1960–1962), National Health and Nutrition Examination Survey (NHANES) I (1971–1974), NHANES II (1976–1980), NHANES III (1988–1994), and NHANES 1999–2000. Diagnosed diabetes was ascertained, and height and weight were measured in adults aged 20–74 years in all surveys. In NHANES II, NHANES III, and NHANES 1999–2000, a fasting glucose level ≥126 mg/dl was used to identify cases among individuals not reporting diabetes. Design-based analyses and Bayesian models estimate the probability that prevalence of diabetes increased within four BMI groups (<25, 25–29, 30–34, and ≥35 kg/m 2 ). RESULTS —In the U.S. population aged 20–74 years between 1976–1980 and 1999–2000, significant increases in the prevalence of diagnosed diabetes (3.3–5.8%, probability >99.9%) were accompanied by nonsignificant increases in undiagnosed diabetes (2.0–2.4%, 66.6%). This resulted in an increase in total diabetes (5.3–8.2%, >99.9%) and a modest nonsignificant increase in the proportion of cases that were diagnosed (62–70%, 62.4%). However, these trends varied considerably by BMI level. In individuals with BMI ≥35 kg/m 2 , diagnosed diabetes increased markedly (from 4.9% in 1960, to 8.6% during 1976–1980, to 15.1% in 1999–2000; probability >99.9%), whereas undiagnosed diabetes declined considerably (12.5% during 1976–1980 to 3.2% in 1999–2000, probability of increase 4.5%) Therefore, the proportion of total diabetes cases that were diagnosed increased from 41 to 83% (probability 99.9%) among individuals with BMI ≥35 kg/m 2 . By comparison, changes in prevalence within BMI strata <35 kg/m 2 were modest and there was no increase in the percent of total cases that were diagnosed. CONCLUSIONS —National surveys over the last several decades have found large increases in diagnosed diabetes, particularly in overweight and obese individuals, but this has been accompanied by large decreases in undiagnosed diabetes only among individuals with BMI ≥35 kg/m 2 . This suggests that improvements in diabetes awareness and detection are most prominent among this subgroup. ADA, American Diabetes Association NHANES, National Health and Nutrition Examination Survey NHES, National Health Examination Survey Footnotes A table elsewhere in this issue shows conventional and Système International (SI) units and conversion factors for many substances. Accepted August 20, 2004. Received May 25, 2004. DIABETES CARE

The authors analyzed national survey data from 1999 through 2010 for adults with self-reported diabetes. During that period, the proportion of survey participants who met recommended treatment targets increased. An estimated 18.8 million adults in the United States have diagnosed diabetes mellitus. 1 Diabetes increases the risk of disabling and life-threatening complications from microvascular disease (affecting the kidneys, eyes, and limbs) and macrovascular disease (involving the coronary vascular, cerebrovascular, and peripheral vascular systems). Two decades ago, the Diabetes Control and Complications Trial (DCCT) 2 and the United Kingdom Prospective Diabetes Study (UKPDS) 3 showed that improved glycemic control is associated with reduced microvascular complications and long-term reductions (at the least) in macrovascular disease. 4 , 5 Subsequent trials showed that lowering blood pressure, reducing cholesterol levels, and avoiding tobacco decreases the incidence of vascular . . .

Screening guidelines are used to help identify prediabetes and diabetes before implementing evidence-based prevention and treatment interventions. We examined screening practices benchmarking against two US guidelines, and the capacity of each guideline to identify dysglycemia. Using 2007-2012 National Health and Nutrition Examination Surveys, we analyzed nationally-representative, cross-sectional data from 5,813 fasting non-pregnant adults aged ≥20 years without self-reported diabetes. We examined proportions of adults eligible for diagnostic glucose testing and those who self-reported receiving testing in the past three years, as recommended by the American Diabetes Association (ADA) and the US Preventive Services Task Force (USPSTF-2008) guidelines. For each screening guideline, we also assessed sensitivity, specificity, and positive (PPV) and negative predictive values in identifying dysglycemia (defined as fasting plasma glucose ≥100 mg/dl or hemoglobin A1c ≥5.7%). In 2007-2012, 73.0% and 23.7% of US adults without diagnosed diabetes met ADA and USPSTF-2008 criteria for screening, respectively; and 91.5% had at least one major risk factor for diabetes. Of those ADA- or USPSTF-eligible adults, about 51% reported being tested within the past three years. Eligible individuals not tested were more likely to be lower educated, poorer, uninsured, or have no usual place of care compared to tested eligible adults. Among adults with ≥1 major risk factor, 45.7% reported being tested, and dysglycemia yields (i.e., PPV) ranged from 45.8% (high-risk ethnicity) to 72.6% (self-reported prediabetes). ADA criteria and having any risk factor were more sensitive than the USPSTF-2008 guideline (88.8-97.7% vs. 31.0%) but less specific (13.5-39.7% vs. 82.1%) in recommending glucose testing, resulting in lower PPVs (47.7-54.4% vs. 58.4%). Diverging recommendations and variable performance of different guidelines may be impeding national diabetes prevention and treatment efforts. Efforts to align screening recommendations may result in earlier identification of adults at high risk for prediabetes and diabetes.

Prevalence of diabetes, impaired fasting glucose, and impaired glucose tolerance in U.S. adults. The Third National Health and Nutrition Examination Survey, 1988-1994. M I Harris , K M Flegal , C C Cowie , M S Eberhardt , D E Goldstein , R R Little , H M Wiedmeyer and D D Byrd-Holt National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD 20892. harrism@ep.niddk.nih.gov Abstract OBJECTIVE: To evaluate the prevalence and time trends for diagnosed and undiagnosed diabetes, impaired fasting glucose, and impaired glucose tolerance in U.S. adults by age, sex, and race or ethnic group, based on data from the Third National Health and Nutrition Examination Survey, 1988-1994 (NHANES III) and prior Health and Nutrition Examination Surveys (HANESs). RESEARCH DESIGN AND METHODS: NHANES III contained a probability sample of 18,825 U.S. adults > or = 20 years of age who were interviewed to ascertain a medical history of diagnosed diabetes, a subsample of 6,587 adults for whom fasting plasma glucose values were obtained, and a subsample of 2,844 adults between 40 and 74 years of age who received an oral glucose tolerance test. The Second National Health and Nutrition Examination Survey, 1976-1980, and Hispanic HANES used similar procedures to ascertain diabetes. Prevalence was calculated using the 1997 American Diabetes Association fasting plasma glucose criteria and the 1980-1985 World Health Organization (WHO) oral glucose tolerance test criteria. RESULTS: Prevalence of diagnosed diabetes in 1988-1994 was estimated to be 5.1% for U.S. adults > or = 20 years of age (10.2 million people when extrapolated to the 1997 U.S. population). Using American Diabetes Association criteria, the prevalence of undiagnosed diabetes (fasting plasma glucose > or = 126 mg/dl) was 2.7% (5.4 million), and the prevalence of impaired fasting glucose (110 to < 126 mg/dl) was 6.9% (13.4 million). There were similar rates of diabetes for men and women, but the rates for non-Hispanic blacks and Mexican-Americans were 1.6 and 1.9 times the rate for non-Hispanic whites. Based on American Diabetes Association criteria, prevalence of diabetes (diagnosed plus undiagnosed) in the total population of people who were 40-74 years of age increased from 8.9% in the period 1976-1980 to 12.3% by 1988-1994. A similar increase was found when WHO criteria were applied (11.4 and 14.3%). CONCLUSIONS: The high rates of abnormal fasting and postchallenge glucose found in NHANES III, together with the increasing frequency of obesity and sedentary lifestyles in the population, make it likely that diabetes will continue to be a major health problem in the U.S.

OBJECTIVE: We studied the incidence of dysglycemia and its prediction of the development of type 1 diabetes in islet cell autoantibody (ICA)-positive individuals. In addition, we assessed whether dysglycemia was sustained. RESEARCH DESIGN AND METHODS: Participants (n = 515) in the Diabetes Prevention Trial-Type 1 (DPT-1) with normal glucose tolerance who underwent periodic oral glucose tolerance tests (OGTTs) were followed for incident dysglycemia (impaired fasting glucose, impaired glucose tolerance, and/or high glucose levels at intermediate time points of OGTTs). Incident dysglycemia at the 6-month visit was assessed for type 1 diabetes prediction. RESULTS: Of 515 participants with a normal baseline OGTT, 310 (60%) had at least one episode of dysglycemia over a maximum follow-up of 7 years. Dysglycemia at the 6-month visit was highly predictive of the development of type 1 diabetes, both in those aged <13 years (P < 0.001) and those aged greater-than-or-equal13 years (P < 0.01). Those aged <13 years with dysglycemia at the 6-month visit had a high cumulative incidence (94% estimate by 5 years). Among those who developed type 1 diabetes after a dysglycemic OGTT and who had at least two OGTTs after the dysglycemic OGTT, 33 of 64 (52%) reverted back to a normal OGTT. However, 26 (79%) of the 33 then had another dysglycemic OGTT before diagnosis. CONCLUSIONS: ICA-positive individuals with normal glucose tolerance had a high incidence of dysglycemia. Incident dysglycemia in those who are ICA positive is strongly predictive of type 1 diabetes. Children with incident dysglycemia have an especially high risk. Fluctuations in and out of the dysglycemic state are not uncommon before the onset of type 1 diabetes.