Intermediate hyperglycaemia to predict progression to type 2 diabetes (ELSA-Brasil): an occupational cohort study in Brazil
Intermediate hyperglycaemia to predict progression to type 2 diabetes (ELSA-Brasil): an occupational cohort study in Brazil
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DOI：
10.1016/s2213-8587(19)30058-0
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发表时间：
2019-04-01
影响因子：
44.5
通讯作者：
Duncan, Bruce B.
中科院分区：
文献类型：
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作者：
Schmidt, Maria Ines;Bracco, Paula A.;Duncan, Bruce B.
背景糖尿病的负担在世界范围内不断增加，糖尿病可以通过对糖耐量受损（IGT）人群的干预来预防。没有口服葡萄糖耐量试验的中度高血糖定义为空腹血糖受损（IFG）和高HbA(1c)，也用于表征风险。我们的目的是在预测谁将发展为糖尿病的能力的基础上，评估五种中度高血糖（也称为前驱糖尿病）定义的预后特性。方法巴西成人健康纵向研究（ELSA-Brasil）是一项职业队列研究，从巴西六个州首府城市的公立大学和研究机构招募35-74岁的在职或退休公务员。我们排除了提供不充分信息以确定糖尿病状态的参与者、没有相关协变量信息的参与者和糖尿病患者。我们根据自我报告、药物使用、空腹血糖（FPG）、2小时血糖和HbA（1c）的测量对2型糖尿病进行分类。我们使用了五种实验室定义的中度高血糖：IGT(2小时血浆葡萄糖>= 7.8 mmol/L [>= 140 mg/dL])；IFG基于美国糖尿病协会（ADA）标准（FPG >= 5.5 mmol/L [>= 100 mg/dL]）；IFG基于WHO标准（FPG >= 6.1 mmol/L [>= 110 mg/dL]）；基于ADA标准的HbA(1c) (HbA1c >= 39 mmol/mol [5.7%])；和HbA（1c）根据国际专家委员会标准，IEC-HbA(1c), （HbA(1c) >= 42 mmol/mol[6.0%]）。我们使用Cox回归估计每个定义的风险，使用逻辑回归估计总体可预测性（受试者工作特征曲线下的面积[AUC]）。我们从2008年8月18日至2010年12月20日招募了15105名参与者，平均随访3.7年（SD 0.63）。糖尿病发病率为2.0 / 100人-年（95% CI 1.8-2.1）。在1199名符合条件的参与者中，6563名（59%）出现了某种形式的中度高血糖。ADA-IFG（4870/11199[43.5%]）、IEC-HbA(1c)（1005[9.0%]）和ADA-HbA(1c)（2299[20.5%]）对糖尿病的预测较差（每100人年3.5-3.6例）。WHO-IFG（1140[10.2%]）和IGT（2245[20.0%]）预测更高的转化率（分别为7.5 / 100人年和5.8 / 100人年）。所有的定义要么敏感性低，要么特异性低。联合试验改善了预后特性，IGT或WHO-IFG联合试验显示出最佳的可预测性，但仍不足（敏感性67.7%,95% CI 64.5-70.1；特异性77.9%,77.1-78.7）。三项基础血糖测试的AUC分别为HbA（1c）的65.0% （95% CI 63.0-66.9）、FPG的74.6% （95% CI 72.7-76.4）和2 h血浆葡萄糖的77.1% (95% CI 75.4-78.8)，而由临床信息组成的评分的AUC为71.6% （95% CI 69.8-73.3）。当该评分与口服葡萄糖耐量试验结果相结合时，AUC达到82.4%（80.9-83.9）。基于WHO标准的IFG和IGT比其他三种中度高血糖定义更能预测糖尿病进展，但其敏感性较低。基于ADA标准的IFG比其他标准具有更好的敏感性，但将几乎一半的成年人分类为中度高血糖，并且很难预测糖尿病。将血糖结果与临床信息相结合可改善高危患者的预后。Elsevier Ltd.版权所有版权所有。
Background The burden of diabetes is increasing worldwide and diabetes can be prevented with intervention in people with impaired glucose tolerance (IGT). Intermediate hyperglycaemia defined without an oral glucose tolerance test as impaired fasting glucose (IFG) and high HbA(1c) are also used to characterise risk. We aimed to assess the prognostic properties of five definitions of intermediate hyperglycaemia (also known as prediabetes) on the basis of their ability to predict who will progress to diabetes.Methods The Brazilian Longitudinal Study of Adult Health (ELSA-Brasil) is an occupational cohort study of active or retired civil servants, aged 35-74 years, recruited from public universities and research institutes in six state capital cities in Brazil. We excluded participants who provided insufficient information to ascertain diabetes status, those without information on relevant covariates, and those with diabetes. We classified type 2 diabetes on the basis of self-report, medication use, measures of fasting plasma glucose (FPG), 2 h plasma glucose, and HbA(1c). We used five laboratory definitions of intermediate hyperglycaemia: IGT (2 h plasma glucose >= 7.8 mmol/L [>= 140 mg/dL]); IFG based on American Diabetes Association (ADA) criteria (FPG >= 5.5 mmol/L [>= 100 mg/dL]); IFG based on WHO criteria (FPG >= 6.1 mmol/L [>= 110 mg/dL]); HbA(1c) based on ADA criteria (HbA1c >= 39 mmol/mol [5.7%]); and HbA(1c) based on International Expert Committee criteria, IEC-HbA(1c), (HbA(1c) >= 42 mmol/mol [6.0%]). We estimated risk of each definition using Cox regression and overall predictability (area under the receiver operating characteristic curve [AUC]) using logistic regression.Findings We recruited 15 105 participants from Aug 18, 2008, to Dec 20, 2010, and followed up for a mean of 3.7 (SD 0.63) years. Diabetes incidence rate was 2.0 per 100 person- years (95% CI 1.8-2.1). Among the 11 199 eligible participants, 6563 (59%) presented with some form of intermediate hyperglycaemia. ADA-IFG (4870/11199 [43.5%), IEC-HbA(1c) (1005 [9.0%]), and ADA-HbA(1c) (2299 [20.5%]) poorly predicted diabetes (3.5-3.6 per 100 person- years). WHO-IFG (1140 [10.2%]) and IGT (2245 [20.0%]) predicted greater conversion (7.5 per 100 person- years and 5.8 per 100 person- years, respectively). All definitions presented either low sensitivity or specificity. Combinations of tests improved prognostic properties, with the combination of IGT or WHO-IFG showing the best, but still insufficient, predictability (sensitivity 67.7%, 95% CI 64.5-70.1; specificity 77.9%, 77.1-78.7). The AUC for the three underlying glycaemic tests was 65.0% (95% CI 63.0-66.9) for HbA(1c), 74.6% (72.7-76.4) for FPG, and 77.1% (75.4-78.8) for 2 h plasma glucose, whereas the AUC for a score composed of clinical information was 71.6% (69.8-73.3). When this score was combined with results of an oral glucose tolerance test, the AUC reached 82.4% (80.9-83.9).Interpretation IFG based on WHO criteria and IGT predict diabetes progression better than do the other three definitions of intermediate hyperglycaemia, but their sensitivity is low. IFG based on ADA criteria has better sensitivity than the others, but classifies almost half of adults as having intermediate hyperglycaemia and poorly predicts diabetes. Combining glycaemic results with clinical information improves prognostic properties of those at risk. Copyright (C) 2019 Elsevier Ltd. All rights reserved.