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Diabetes

Risk of Progression to Diabetes Among Older Adults With Prediabetes

Educational Objective: To compare different prediabetes definitions and characterize the risks of prediabetes and diabetes among older adults in a community-based setting.

1 Credit CME

JAMA Internal Medicine

Published Online: February 8, 2021

Original Investigation

Article Information and Disclosures

Mary R. Rooney, PhD, MPH¹;

Andreea M. Rawlings, PhD²;

James S. Pankow, PhD, MPH³;

Justin B. Echouffo Tcheugui, MD, MPhil, PhD⁴;

Josef Coresh, MD, PhD¹;

A. Richey Sharrett, MD¹;

Elizabeth Selvin, PhD, MPH¹

Author Affiliations

¹Welch Center for Prevention, Epidemiology, and Clinical Research, Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
²Kaiser Permanente Center for Health Research, Portland, Oregon
³Division of Epidemiology and Community Health, University of Minnesota, Minneapolis
⁴Division of Endocrinology, Diabetes, and Metabolism, Johns Hopkins University, Baltimore, Maryland

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Key Points

Question What is the risk of progression to diabetes among older adults with prediabetes (based on glycated hemoglobin level of 5.7%-6.4%, fasting glucose levels of 100-125 mg/dL, either, or both) in a community-based population?

Findings In this cohort study of 3412 older adults, the prevalence of prediabetes (mean [SD] age, 75.6 [5.2] years) was high and differed substantially depending on the definition used, with estimates ranging from 29% for glycated hemoglobin levels of 5.7% to 6.4% and fasting glucose levels of 100 to 125 mg/dL to 73% for either glycated hemoglobin levels of 5.7% to 6.4% or fasting glucose levels of 100 to 125 mg/dL. During the 6 years of follow-up, death or regression to normoglycemia from prediabetes was more frequent than progression to diabetes.

Meaning Prediabetes may not be a robust diagnostic entity in older age.

Abstract

Importance The term prediabetes is used to identify individuals at increased risk for diabetes. However, the natural history of prediabetes in older age is not well characterized.

Objectives To compare different prediabetes definitions and characterize the risks of prediabetes and diabetes among older adults in a community-based setting.

Design, Setting, and Participants In this prospective cohort analysis of 3412 older adults without diabetes from the Atherosclerosis Risk in Communities Study (baseline, 2011-2013), participants were contacted semiannually through December 31, 2017, and attended a follow-up visit between January 1, 2016, and December 31, 2017 (median [range] follow-up, 5.0 [0.1-6.5] years).

Exposures Prediabetes defined by a glycated hemoglobin (HbA_1c) level of 5.7% to 6.4%, impaired fasting glucose (IFG) level (FG level of 100-125 mg/dL), either, or both.

Main Outcomes and Measures Incident total diabetes (physician diagnosis, glucose-lowering medication use, HbA_1c level ≥6.5%, or FG level ≥126 mg/dL).

Results A total of 3412 participants without diabetes (mean [SD] age, 75.6 [5.2] years; 2040 [60%] female; and 572 [17%] Black) attended visit 5 (2011-2013, baseline). Of the 3412 participants at baseline, a total of 2497 participants attended the follow-up visit or died. During the 6.5-year follow-up period, there were 156 incident total diabetes cases (118 diagnosed) and 434 deaths. A total of 1490 participants (44%) had HbA_1c levels of 5.7% to 6.4%, 1996 (59%) had IFG, 2482 (73%) met the HbA_1c or IFG criteria, and 1004 (29%) met both the HbA_1c and IFG criteria. Among participants with HbA_1c levels of 5.7% to 6.4% at baseline, 97 (9%) progressed to diabetes, 148 (13%) regressed to normoglycemia (HbA_1c, <5.7%), and 207 (19%) died. Of those with IFG at baseline, 112 (8%) progressed to diabetes, 647 (44%) regressed to normoglycemia (FG, <100 mg/dL), and 236 (16%) died. Of those with baseline HbA_1c levels less than 5.7%, 239 (17%) progressed to HbA_1c levels of 5.7% to 6.4% and 41 (3%) developed diabetes. Of those with baseline FG levels less than 100 mg/dL, 80 (8%) progressed to IFG (FG, 100-125 mg/dL) and 26 (3%) developed diabetes.

Conclusions and Relevance In this community-based cohort study of older adults, the prevalence of prediabetes was high; however, during the study period, regression to normoglycemia or death was more frequent than progression to diabetes. These findings suggest that prediabetes may not be a robust diagnostic entity in older age.

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Article Information

Accepted for Publication: December 8, 2020.

Published Online: February 8, 2021. doi:10.1001/jamainternmed.2020.8774

Correction: This article was corrected on April 5, 2021, to fix incorrect incidence rates in Results and in Table 2. The Supplement was also replaced to show corrected incidence rates in eTable 3. In addition, the first sentence of the Findings portion of the Key Points was amended to included omitted text.

Corresponding Author: Mary R. Rooney, PhD, MPH, Welch Center for Prevention, Epidemiology, and Clinical Research, Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, 2024 E Monument St, Ste 2-600, Baltimore, MD 21287 (mroone12@jhu.edu).

Author Contributions: Dr Rooney had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Rooney, Selvin.

Acquisition, analysis, or interpretation of data: All authors.

Drafting of the manuscript: Rooney.

Critical revision of the manuscript for important intellectual content: Rawlings, Pankow, Echouffo Tcheugui, Coresh, Sharrett, Selvin.

Statistical analysis: Rooney, Rawlings.

Obtained funding: Coresh, Selvin.

Administrative, technical, or material support: Pankow, Coresh, Selvin.

Supervision: Coresh, Selvin.

Conflict of Interest Disclosures: Dr Pankow reported receiving grants from the National Institutes of Health during the conduct of the study. Dr Coresh reported receiving grants from the National Institutes of Health during the conduct of the study and outside the submitted work. Dr Sharrett reported receiving grants from the Johns Hopkins Bloomberg School of Public Health during the conduct of the study. Dr Selvin reported receiving grants from the National Institutes of Health during the conduct of the study and grants from the National Institutes of Health and the Foundation for the National Institutes of Health outside the submitted work. No other disclosures were reported.

Funding/Support: The Atherosclerosis Risk in Communities study has been funded in whole or in part with federal funds from the National Heart, Lung, and Blood Institute (NHLBI), National Institutes of Health, Department of Health and Human Services, under contracts HHSN268201700001I, HHSN268201700002I, HHSN268201700003I, HHSN268201700005I, and HHSN268201700004I. Research reported in this publication was supported by grants T32HL007024 (Dr Rooney) and K24HL152440 (Dr Selvin) from the NHLBI and grant R01DK089174 from the National Institute of Diabetes and Digestive and Kidney Diseases (Dr Selvin).

Role of the Funder/Sponsor: The funding sources had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Disclaimer: The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

Meeting Presentation: Presented in part at the American Heart Association Epi|Lifestyle Scientific Sessions; March 4 and 5, 2020; Phoenix, Arizona.

Additional Contributions: We thank the staff and participants of the Atherosclerosis Risk in Communities Study for their important contributions.

AMA CME Accreditation Information

Credit Designation Statement: The American Medical Association designates this Journal-based CME activity activity for a maximum of 1.00  AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to:

1.00 Medical Knowledge MOC points in the American Board of Internal Medicine's (ABIM) Maintenance of Certification (MOC) program;;
1.00 Self-Assessment points in the American Board of Otolaryngology – Head and Neck Surgery’s (ABOHNS) Continuing Certification program;
1.00 MOC points in the American Board of Pediatrics’ (ABP) Maintenance of Certification (MOC) program;
1.00 Lifelong Learning points in the American Board of Pathology’s (ABPath) Continuing Certification program; and
1.00 credit toward the CME of the American Board of Surgery’s Continuous Certification program

It is the CME activity provider's responsibility to submit participant completion information to ACCME for the purpose of granting MOC credit.