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Prognostic value of haemoglobin A1c and fasting plasma glucose for incident diabetes and implications for screening

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Abstract

The aim of this analysis is to compare screening strategies with haemoglobin A1c (HbA1c), fasting plasma glucose (FPG) or combined measures in the identification of individuals at high risk for diabetes. Applying American Diabetes Association thresholds for FPG and HbA1c screening, 6,803 subjects free of diabetes were classified as non-diabetic, pre-diabetic and possibly diabetic by FPG (<100, 100–125 and >125 mg/dl) and HbA1c (<5.7, 5.7–6.4 and >6.4%). Hazard ratios, sensitivity and specificity were estimated for individuals with pre-diabetes with respect to incident diabetes in the following 5 years. Areas under the receiver operating characteristic curves (AUC) were estimated for levels of FPG ≤ 125 mg/dl and HbA1c ≤ 6.4% in diabetes prediction. Although FPG and HbA1c screenings poorly agreed in classifying individuals as pre-diabetic, hazard ratios [95% confidence interval] for incident diabetes were similarly increased in univariate models in the two pre-diabetic groups: FPG 100–125 mg/dl, 4.72 [3.69; 6.05]; HbA1c 5.7–6.4%, 3.97 [3.05; 5.23]. HbA1c and FPG had comparable AUCs (FPG, 0.732; HbA1c, 0.725) and consequently similar 5-year sensitivities and specificities for their pre-diabetes definitions (when the lower cut-off for HbA1c-defined pre-diabetes was increased to a level between 5.8 and 5.9%). Combining HbA1c and FPG increased the AUC to 0.778, and a further increase to 0.817 was seen with additional inclusion of conventional risk factors. FPG and HbA1c have comparable (yet insufficient) abilities in identifying individuals at high risk for diabetes. Effectiveness of a diabetes screening program could be improved by a risk score including FPG and HbA1c.

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Abbreviations

ADA:

American Diabetes Association

AUC:

Area under the receiver operating characteristic curve

FPG:

Fasting plasma glucose

FOS-SCM:

Framingham Offspring Study—Simple Clinical Model

IFG:

Impaired fasting glucose

IGT:

Impaired glucose tolerance

I-HbA1c :

Isolated HbA1c-defined pre-diabetes

I-IFG:

Isolated impaired fasting glucose

IQR:

Interquartile range

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Acknowledgments

The ESTHER study was funded by the Baden-Württemberg state Ministry of Science, Research and Arts (Stuttgart, Germany), the Federal Ministry of Education and Research (Berlin, Germany) and the Federal Ministry of Family Affairs, Senior Citizens, Women and Youth (Berlin, Germany).

Conflict of interest

The authors have no conflict of interest to disclose.

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Authors and Affiliations

  1. Division of Clinical Epidemiology and Aging Research, German Cancer Research Center, Im Neuenheimer Feld 581, 69120, Heidelberg, Germany

    Ben Schöttker, Elke Raum, Dietrich Rothenbacher, Heiko Müller & Hermann Brenner

  2. Institute of Epidemiology and Medical Biometry, Ulm University, 89081, Ulm, Germany

    Dietrich Rothenbacher

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  1. Ben Schöttker
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  2. Elke Raum
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  3. Dietrich Rothenbacher
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Correspondence to Ben Schöttker.

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Schöttker, B., Raum, E., Rothenbacher, D. et al. Prognostic value of haemoglobin A1c and fasting plasma glucose for incident diabetes and implications for screening. Eur J Epidemiol 26, 779–787 (2011). https://doi.org/10.1007/s10654-011-9619-9

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  • DOI: https://doi.org/10.1007/s10654-011-9619-9

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