Choice of HbA1c threshold for identifying individuals at high risk of type 2 diabetes and implications for diabetes prevention programmes: a cohort study

Abstract

Background Type 2 diabetes (T2D) is common and increasing in prevalence. It is possible to prevent or delay T2D using lifestyle intervention programmes. Entry to these programmes is usually determined by a measure of glycaemia in the ‘intermediate’ range. This paper investigated the relationship between HbA1c and future diabetes risk and determined the impact of varying thresholds to identify those at high risk of developing T2D. Methods We studied 4227 participants without diabetes aged ≥ 40 years recruited to the Exeter 10,000 population cohort in South West England. HbA1c was measured at study recruitment with repeat HbA1c available as part of usual care. Absolute risk of developing diabetes within 5 years, defined by HbA1c ≥ 48 mmol/mol (6.5%), according to baseline HbA1c, was assessed by a flexible parametric survival model. Results The overall absolute 5-year risk (95% CI) of developing T2D in the cohort was 4.2% (3.6, 4.8%). This rose to 7.1% (6.1, 8.2%) in the 56% (n = 2358/4224) of participants classified ‘high-risk’ with HbA1c ≥ 39 mmol/mol (5.7%; ADA criteria). Under IEC criteria, HbA1c ≥ 42 mmol/mol (6.0%), 22% (n = 929/4277) of the cohort was classified high-risk with 5-year risk 14.9% (12.6, 17.2%). Those with the highest HbA1c values (44–47 mmol/mol [6.2–6.4%]) had much higher 5-year risk, 26.4% (22.0, 30.5%) compared with 2.1% (1.5, 2.6%) for 39–41 mmol/mol (5.7–5.9%) and 7.0% (5.4, 8.6%) for 42–43 mmol/mol (6.0–6.1%). Changing the entry criterion to prevention programmes from 39 to 42 mmol/mol (5.7–6.0%) reduced the proportion classified high-risk by 61%, and increased the positive predictive value (PPV) from 5.8 to 12.4% with negligible impact on the negative predictive value (NPV), 99.6% to 99.1%. Increasing the threshold further, to 44 mmol/mol (6.2%), reduced those classified high-risk by 59%, and markedly increased the PPV from 12.4 to 23.2% and had little impact on the NPV (99.1% to 98.5%). Conclusions A large proportion of people are identified as high-risk using current thresholds. Increasing the risk threshold markedly reduces the number of people that would be classified as high-risk and entered into prevention programmes, although this must be balanced against cases missed. Raising the entry threshold would allow limited intervention opportunities to be focused on those most likely to develop T2D.

Machine Learning Approach to Metabolomic Data Predicts Type 2 Diabetes Mellitus Incidence

“…Remarkably, ML was capable of predicting T2DM incidence within four years, although patients who did develop T2DM and those who did not were not strikingly different in terms of their anthropometric or HbA1c data. A recent study highlighted the challenge in classifying HbA1c levels regarding the risk of developing diabetes, noting that many individuals are already classified as high-risk under current HbA1c thresholds [12]. They suggested that raising the threshold to an HbA1c value of 6.0% could improve the positive predictive value (=precision) to 12.4%.…”

Diagnostic Performance of Sex-Specific Modified Metabolite Patterns in Urine for Screening of Prediabetes

“…These reports are in line with the findings in our cohorts (Figure 3). Approaches to adjust the diagnostic threshold of HbA 1c (24)(25)(26) or to combine FPG and HbA 1c for screenings were not real breakthroughs (5). Consequently, a considerable number of individuals with prediabetes remain undiagnosed using the available and recommended diagnostic parameters for prediabetes screening.…”

Processed meat consumption increases risk of type 2 diabetes mellitus in adults aged 40 years and older

“…The measurement of HbA1c was performed by a physician or paramedic (Yes = HbA1c  6.5% and No = HbA1c <6.5%). (38) 21 C…”