Categories of glucose tolerance and continuous glycemic measures and mortality

  • Bernd Kowall
  • Wolfgang Rathmann
  • Margit Heier
  • Guido Giani
  • Annette Peters
  • Barbara Thorand
  • Cornelia Huth
  • Andrea Icks
  • Christine Meisinger


We investigated the association of undiagnosed diabetes, previously known diabetes and prediabetes (WHO 1999 classification) with all-cause and cause-specific mortality in an older German population. Previous study results for mortality in patients with very low levels of HbA1c, fasting plasma glucose (FPG), and 2-h plasma glucose (2hPG) are still inconclusive. Thus we have extended the analyses to continuous measures of glycemia. A total of 1,466 subjects aged 55–74 years from the population-based KORA survey S4 (conducted from 1999 to 2001) were included in our observational mortality study (152 subjects with previously known diabetes, and 1,314 further subjects who underwent oral glucose tolerance tests). Mortality was followed up for a maximum of 10.0 years (median follow-up 8.8 years). A total of 180 (12.3%) of the 1,466 subjects have died during the follow-up period. The age- and sex-adjusted hazard ratios for all-cause mortality were 2.6 (95%CI, 1.7–3.8) for known diabetes, 2.8 (95%CI, 1.7–4.4) for undiagnosed diabetes, and 1.1 (95%CI, 0.8–1.7) for prediabetes [reference: normal glucose tolerance (NGT)]. After multivariable adjustment, undiagnosed diabetes was associated with 3.0-fold increased cancer mortality, 1.1-fold increased cardiovascular mortality, and 4.7-fold increased non-cancer, non-cardiovascular mortality compared with NGT. For HbA1c, FPG, and 2hPG, J-shaped associations with all-cause mortality were observed. Undiagnosed diabetes is associated with increased all-cause, cancer, and non-cancer non-cardiovascular mortality, but not with cardiovascular mortality in this older population. All-cause mortality in undiagnosed diabetes is similar to that in previously known diabetes but much higher than mortality in prediabetes and NGT.


Type 2 diabetes All-cause mortality Cancer mortality Cardiovascular mortality 



Body mass index


Confidence interval


Cardiovascular disease


Diabetes epidemiology: collaborative analysis of diagnostic criteria in Europe


Fasting plasma glucose


High-density lipoprotein


Homeostatic model assessment of insulin resistance


Hazard ratio


International classification of diseases


Integrated discrimination improvement


Impaired fasting glucose


Impaired glucose tolerance


Cooperative health research in the region of Augsburg


Normal glucose tolerance


National Health and Nutrition Examination Survey


Net reclassification improvement


Oral glucose tolerance test




2-h plasma glucose


World Health Organization


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Copyright information

© Springer Science+Business Media B.V. 2011

Authors and Affiliations

  • Bernd Kowall
    • 1
  • Wolfgang Rathmann
    • 1
  • Margit Heier
    • 2
  • Guido Giani
    • 1
  • Annette Peters
    • 2
  • Barbara Thorand
    • 2
  • Cornelia Huth
    • 2
  • Andrea Icks
    • 1
    • 3
  • Christine Meisinger
    • 2
  1. 1.Institute of Biometrics and Epidemiology, German Diabetes CenterLeibniz Center for Diabetes Research at Heinrich Heine University DüsseldorfDüsseldorfGermany
  2. 2.Helmholtz Zentrum München, German Research Center for Environmental HealthInstitute of Epidemiology IINeuherbergGermany
  3. 3.Department of Public Health, Faculty of MedicineHeinrich Heine UniversityDüsseldorfGermany

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