Relationship between fasting plasma glucose and glycosylated hemoglobin - Potential for false-positive diagnoses of type 2 diabetes using new diagnostic criteria

Context New criteria for the diagnosis of type 2 diabetes mellitus have recently been introduced that lowered the diagnostic fasting plasma glucose (FPC) concentration from 7.8 to 7.0 mmol/L (140 to 126 mg/dL). Objective To determine if individuals with diabetes diagnosed by the new FPC concentration criterion would have excessive glycosylation (elevated hemoglobin [HbA(1c)] levels). Definitions We determined the distribution of HbA(1c) levels in individuals using 4 classifications: (1) normal by the new criterion (FPG concentration <6.1 mmol/L [110 mg/dL]; (2) impaired fasting glucose by the new criterion (FPG concentration of 6.1-6.9 mmol/L [110-125 mg/dL]); (3) diabetes diagnosed solely by the new FPG concentration criterion of 7.0 through 7.7 mmol/L (126-139 mg/dL); and (4) diabetes diagnosed. by the previous FPG concentration criterion of 7.8 mmol/L (140 mg/dL) or higher. Design Cross-sectional analysis of 2 large data sets (NHANES III and Meta-Analysis Research Group [MRG] on the Diagnosis of Diabetes Using Glycated Hemoglobin) that contained individuals in whom FPG concentrations, 2-hour glucose concentrations using an oral glucose tolerance test, and an HbA(1c) level were simultaneously measured. We cross-tabulated FPG concentrations (<6.1 mmol/L [110 mg/dL], 6.1-6.9 mmol/L [110-125 mg/dL],7.0-7.7 mmol/L [126-139 mg/dl],and greater than or equal to 7.8 mmol/L [140 mg/dl]) and HbA(1c) levels separated into 3 intervals: normal, less than the upper limit of normal (ULN); slightly elevated, ULN to ULN plus 1%; and high, higher than ULN plus 1%. Results Among subjects with normal FPC concentrations, HbA(1c) levels in the NHANES I II land the MRC) data sets were normal in 97.3% (96.2%), slightly elevated in 2.7% (3.6%), and high in 0.1% (0.2%). Among individuals with impaired fasting glucose, HbA(1c) concentrations were normal in 86.7% (81.4%), slightly elevated in 13.1% (16.4%), and high in 0.2% (2.2%). Among diabetic patients diagnosed by the new FPC criterion only, HbA(1c) levels were normal in 60.9% (59.6%), slightly elevated in 35.8% (32.8%), and high in 3.4% (7.6%). In diabetic patients diagnosed by the former FPG criterion, HbA(1c) levels were normal in 18.6% (16.7%), slightly elevated in 32.5% (21.0%), and high in 48.9% (62.3%). Conclusions About 60% of the new cohort of diabetic patients in both data sets have normal HbA(1c) levels. We believe that diabetes should not be diagnosed in those with FPC concentrations less than 7.8 mmol/L (140 mg/dL) unless excessive glycosylation is evident. Individuals without excessive glycosylation but with moderate elevations of FPG concentrations (6.1-7.7 mmol/L [110-139 mg/dl]) should be diagnosed as having impaired fasting glucose and treated with an appropriate diet and exercise. This diagnostic labeling achieves the goal of early intervention without subjecting these persons to the potentially negative insurance, employment, social, and psychological consequences of a diagnosis of diabetes mellitus.